Primary Health Care Definition

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The World Health Organisation (WHO) is the official sponsor, as it were, for the PHC concept and it is defined as:

The approach to health care proposed in the WHO definition represents a significant departure from the traditional model of so called "health" care delivery. Whilst all PHC practice should be sensitive to consumers' needs and wants, it should always ultimately be empowering, that is, it is about increasing a client's self-determination and enhancing cooperation. The traditional model did not support these goals. Instead, it tended to make client's dependent on the health system and professionals within it.

Typically, a person went about the business of living until becoming sick, ill or injured, whereupon a visit was made to a local doctor or hospital or medical clinic. Treatment was dispensed and the person (who was called a patient , a term which itself implies passivity and dependence) was supposed to dutifully follow instructions in order to become cured. Once cured (indeed, if or supposedly cured would be more appropriate) the person was left to simply return to the business of living as before.

This did not empower the person. There was no attempt to examine lifestyle causes of the illness or injury, no attempt to educate the person in ways to avoid further problems. This system was certainly of benefit to the doctors, whose power, prestige and status (not to mention income) was magnified and secure. Whilst a large number of dependent patients was good for business for doctors, who typically hid this thought from public airing behind a great deal of rhetoric, it was not good for individuals, families (as units of economic consumption) or communities. Indeed, the economic cost alone to the nation became an intolerable burden, from which we in Australia have not yet recovered.

The COPC Process

It is helpful to think of the COPC process in five steps:  

1. Determining our community, 2. Characterizing our community in terms of its health status, 3. Prioritizing the health needs of our community, 4. Developing specific interventions to address priority needs, and 5. Evaluating the effectiveness of the interventions.

Step 1 - Who is our Community?

The provider is encouraged to ask these questions: who does my practice serve, who could my practice serve, and who should my practice serve?   This can be easy in a rural practice because the geographic boundaries are often quite clear.   The questions are equally important for urban providers, albeit more challenging to answer.   Providers can map the zip codes of their current patients to gain a better understanding of the area they actually serve.   The point of this step is to identify the population group that the provider hopes to positively impact, including those critical individuals who are currently outside of the community's health care system.   Though not homogeneous, rural Utah is thought to be more readily divided into some geographic entities with some recognized boundaries.

Step 2 - Characterizing our Community

This is the data-gathering step, which may occur over many weeks and becomes an ongoing part of the practice.   The primary care practice, in partnership with community members, needs to identify the multitude of health problems affecting the community.   We recommend that these health problems be organized according to key age groups within the population.   For example, the U.S. Public Health Service programs which serve medically undeserved populations gather information for five groups: pediatric, adolescent, adult, geriatric, and perinatal.

There are many Utah sources of quantitative data available, including; vital statistics derived from birth and death certificates, hospital admission and discharge data, emergency room utilization, police reports (e.g., substance abuse, domestic abuse, D.W.I.), and health department reports both local and state.   There are also a number of national data sources.   These sources can be extrapolated to smaller areas, including those from the National Center for Health Statistics and the Centers for Disease Control and Prevention.   Finally, we must emphasize the importance of qualitative data derived from the community through techniques such as patient surveys, focus groups, and key informant surveys of individuals from relevant organizations.

Step 3 - Prioritizing Important Health Problems

For each age group, the listing of the health problems identified needs to be prioritized in order of importance.   This is a critical point for community input.   The provider needs to understand the community's perspective on health problems.   From a medical standpoint, we often view importance by the volume of the problem, the impact the problem has on the community whether frequent or rare, or whether the problem results in significant morbidity or mortality.   However, the most important problems are those that the community feels are their greatest concerns.   These prioritized lists suggest the order in which health concerns should be approached.

Step 4 - Implementing Targeted Intervention Programs

For those problems the practice chooses to emphasize, the practice needs to develop a strategy and methodology for positively impacting the problem.   As one might predict, the majority of proposed interventions clearly are preventive in nature.   As practitioners study these priority health problems and consider interventions, they are exploring the breadth of preventive medicine and incorporating a variety of medical, social, and educational interventions.   Obviously in the real world, the choice of interventions is affected by important concerns such as cost (dollars and personnel), likelihood for success, and the availability of community partnerships. Sometimes the intervention may be as simple as the inclusion of a preventive health flow chart in the medical record, participating in a health fair to increase awareness of major health concerns, or participation in a community campaign to raise childhood immunization levels.

Step 5 - Monitoring and Evaluation

This final step is critical to complete the COPC process.   Consistent with the data gathering and monitoring efforts described in the Total Quality Management and Continuous Quality Improvement literature (Blumenthal, 1993), the practice needs to collect data to determine the effectiveness of their interventions.   Not only does this evaluation process allow us to improve or eliminate interventions that are not successful, it encourages us to celebrate, with our community partners, those interventions that do succeed.

Conclusion

Health professions education must look beyond the medical model to a more health oriented model (Smith et. al., 1991).    Community-oriented primary care is a health care delivery paradigm with proven effectiveness and application in our nation's health care system (Institute of Medicine, 1984; Kukulka, Christianson, Moscovice, DeVries, 1994).

COPC is one approach that systematically identifies and addresses the health care needs of an individual and a defined community in an integrated fashion.   COPC can provide a number of opportunities to develop more effective public health programs, such as tracking infectious diseases, developing immunization programs, setting up lead poisoning abatement programs or developing teen pregnancy prevention programs.   One of the benefits of the COPC model includes the ability to change negative health behaviors with targeted interventions and preventive programs.   These programs offer the opportunity to observe the impact of these interventions and document its usefulness.   COPC also has the ability to empower the community to manage its own care by identifying resources and expertise (Mouton, Cash, Shore, 2001).

Equally important, the COPC model appears to offer an effective educational paradigm for health professionals to gain a greater appreciation for the importance of preventive health care in their practices.   Finally, it has been our experience that, through the techniques discussed in this article, health care providers are able to comprehend this approach to health care delivery.  

Our hope is that more of Utah's providers will consider incorporating these principles into their practices for the benefit of their communities.